Pediatric Patients with Emergency Severity Index Level 2

The Emergency Severity Index is a five level triage instrument.

Patients, pediatric or adult, who need immediate potentially life-saving treatment are Level 1, the highest level.

Patients, again pediatric or adult, who are at high risk or potentially high risk due to their history or assessment are Level 2.

Examples of Pediatric Patients with ESI Level 2 are given in Chapter 6, table 6-3, p 47 of the Emergency Severity Index Handbook* (The list is not complete and other pediatric conditions can be ESI Level 2).

Immunocompromised patients with fever
Hemophilia patients with possible acute bleeds
• Joint pain or swelling
• History of fall or injury
• Vital signs and/or mental status outside of baseline
Febrile infant <28 days of age with fever ≥38.0°C rectal
Hypothermic infants <90 days of age with temperature <36.5°C rectal
Rule out meninigitis (headache/stiff neck/fever/lethargy/irritability)
Seizures–prolonged postictal period (altered level of consciousness)
Moderate to severe croup
Lower airway obstruction (moderate to severe)
• Bronchiolitis
• Reactive airway disease (asthma)
• Respiratory distress
– Tachypnea
– Tachycardia
– Increased effort (nasal flaring, retractions)
– Abnormal sounds (grunting)
– Altered mental status

Pediatric patients who do not meet criteria for ESI Level 1 or Level 2 are triaged to Level 3, 4, or 5 based on resource use as discussed in my blog post The Emergency Severity Index: A Five Level Triage Tool Available For Download.

Pediatric patients who are triaged to Level 3 should have their vital signs considered. If the vital signs exceed the danger levels as listed on p 29 of the ESI Handbook*, then the clinician should consider up-triaging the patient to Level 2.

Danger Zone Vital Signs:

newborn to < 3 months—Heart rate > 180, Respiratory rate > 50, Oxygen saturation < 92% (by oximeter)
3 months to 3 years—Heart rate > 160, Respiratory rate > 40, Oxygen saturation < 92% (by oximeter)
3 to 8 years—Heart rate > 140, Respiratory rate > 30, Oxygen saturation < 92% (by oximeter)
> 8 years—Heart rate > 100, Respiratory rate > 20, Oxygen saturation < 92% (by oximeter)

*Gilboy N, Tanabe T, Travers D, Rosenau AM. Emergency Severity Index (ESI): A Triage
Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition.
AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. November 2011. available at

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